MAOs Urge CMS to Include FFS Adjuster in RADV Audits

September 5, 2019

As the prolonged comment period for Risk Adjustment Data Validation (RADV) provisions contained in a November 2018 proposed rule closed on Aug. 28, numerous insurers and at least two trade organizations railed against CMS’s proposal to use an extrapolation methodology that they claimed could lead to inflated audit recoveries. The flawed methodology will ultimately skew the Medicare Advantage bidding process and could impact beneficiary cost-sharing and MA product offerings, several organizations warned.

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As the prolonged comment period for Risk Adjustment Data Validation (RADV) provisions contained in a November 2018 proposed rule closed on Aug. 28, numerous insurers and at least two trade organizations railed against CMS’s proposal to use an extrapolation methodology that they claimed could lead to inflated audit recoveries. The flawed methodology will ultimately skew the Medicare Advantage bidding process and could impact beneficiary cost-sharing and MA product offerings, several organizations warned.

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Tech-Focused Startup Insurers Unveil MA Intentions for 2020

September 5, 2019

Whether they are new to the insurance market altogether or got their start on the Affordable Care Act (ACA) exchanges, many insurance startups this fall are placing their bets on Medicare Advantage. Health care technology firm Cavulus estimates that 14 new MA organizations plan to enter the market, pending regulatory approval, while several existing MA startups are doubling down on their product offerings and/or service area.

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Whether they are new to the insurance market altogether or got their start on the Affordable Care Act (ACA) exchanges, many insurance startups this fall are placing their bets on Medicare Advantage. Health care technology firm Cavulus estimates that 14 new MA organizations plan to enter the market, pending regulatory approval, while several existing MA startups are doubling down on their product offerings and/or service area.

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Smaller Medicaid MCOs Make Moves in Michigan

Continuing an ongoing trend of consolidation among smaller Medicaid managed care organizations in and around Michigan, Priority Health recently unveiled plans to acquire Total Health Care, Inc., a Detroit-based HMO. The organizations did not disclose financial terms of the deal, but said they plan to set up a $25 million foundation to help improve health in Detroit-area communities.

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Continuing an ongoing trend of consolidation among smaller Medicaid managed care organizations in and around Michigan, Priority Health recently unveiled plans to acquire Total Health Care, Inc., a Detroit-based HMO. The organizations did not disclose financial terms of the deal, but said they plan to set up a $25 million foundation to help improve health in Detroit-area communities.

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Revamped MPF Raises Red Flags for Consumer Advocates

September 5, 2019

With seven weeks to go before the start of the 2020 Annual Election Period, CMS on Aug. 27 unveiled its newly redesigned Medicare Plan Finder (MPF) that signified the tool’s first major makeover in nearly a decade. Launch of the new MPF drew immediate criticism from beneficiary advocates, although their concerns appeared largely connected to the timing of its release and recent updates to the Medicare Communications and Marketing Guidelines (MCMG) rather than the functionality of the tool itself.

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With seven weeks to go before the start of the 2020 Annual Election Period, CMS on Aug. 27 unveiled its newly redesigned Medicare Plan Finder (MPF) that signified the tool’s first major makeover in nearly a decade. Launch of the new MPF drew immediate criticism from beneficiary advocates, although their concerns appeared largely connected to the timing of its release and recent updates to the Medicare Communications and Marketing Guidelines (MCMG) rather than the functionality of the tool itself.

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News Briefs

September 5, 2019

✦ The North Carolina Dept. of Health and Human Services (DHHS) on Sept. 3 said it would not begin phasing in the implementation of its new managed Medicaid program on Nov. 1 and instead deploy a statewide transition from fee-for-service to managed care on Feb. 1, 2020. The transition was initially scheduled to roll out in two phases, but was adjusted “because DHHS cannot implement critical actions to go-live with managed care under the current continuing resolution budget,” the agency explained. DHHS said it has extended open enrollment for beneficiaries in the 27 counties that were scheduled to transition in November. Four managed care organizations will serve the new program statewide; Centene Corp. has a regional contract (RMA 2/7/19, p. 5). Visit https://bit.ly/2lYQNNd.

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✦ The North Carolina Dept. of Health and Human Services (DHHS) on Sept. 3 said it would not begin phasing in the implementation of its new managed Medicaid program on Nov. 1 and instead deploy a statewide transition from fee-for-service to managed care on Feb. 1, 2020. The transition was initially scheduled to roll out in two phases, but was adjusted “because DHHS cannot implement critical actions to go-live with managed care under the current continuing resolution budget,” the agency explained. DHHS said it has extended open enrollment for beneficiaries in the 27 counties that were scheduled to transition in November. Four managed care organizations will serve the new program statewide; Centene Corp. has a regional contract (RMA 2/7/19, p. 5). Visit https://bit.ly/2lYQNNd.

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Insurers Push for Changes to SUD Treatment Privacy Rules

September 2, 2019

A recent federal proposal — which would loosen privacy rules surrounding substance use disorder (SUD) treatment — is being applauded by health insurer trade groups who argue the current regulations are outdated and can hamper care coordination.

However, some advocates say legislation is still needed to fully align privacy regulations for SUD treatment with the Health Insurance Portability and Accountability Act (HIPAA), which applies to other forms of physical and behavioral health care. Others, meanwhile, are worried that such changes would weaken patient privacy protections and discourage those struggling with SUD from getting care.

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A recent federal proposal — which would loosen privacy rules surrounding substance use disorder (SUD) treatment — is being applauded by health insurer trade groups who argue the current regulations are outdated and can hamper care coordination.
However, some advocates say legislation is still needed to fully align privacy regulations for SUD treatment with the Health Insurance Portability and Accountability Act (HIPAA), which applies to other forms of physical and behavioral health care. Others, meanwhile, are worried that such changes would weaken patient privacy protections and discourage those struggling with SUD from getting care.

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